Cryoablation in 350 Nuss procedures: Evolution of hospital length of stay and opioid use

Children and the Opioid Crisis: We Can Make a Difference

The use of opioid-sparing and opioid-free strategies in children can provide adequate analgesia while decreasing the risk of adverse events and contributing to the ongoing battle against the opioid crisis. However, every child must be evaluated individually so that a safe and efficacious perioperative pain management plan can be created. A working knowledge of the risks and benefits of opioids, nonopioid adjuncts, and regional anesthesia along with the ethical considerations for balancing stewardship and beneficent care is essential to the success of these strategies. As perioperative practitioners caring for children, we have an obligation to consider opioid-sparing and opioid-free strategies to promote overall best outcomes. We can make a difference, one child at a time.

Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review

This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.

Benefits of the Erector Spinae Plane Block before Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity

Thoracic surgery causes significant pain despite standard multimodal analgesia. Intraoperative cryoanalgesia may be a solution. The onset of the clinical effect of cryoanalgesia can take 12-36 h. The addition of a regional anaesthesia before the cryoanalgesia procedure can enable analgesic protection for the patient during this period. The main aim of the study was to evaluate the benefits of the erector spinae plane (ESP) block prior to Nuss surgery. The 'control' group consisted of 10 teenagers who underwent cryoablation together with intravenous multimodal analgesia according to the standard protocol. The 'intervention' group included 26 teenage patients who additionally received an erector spinae plane block before operation. Pain relief (p = 0.015), opioid use (p = 0.009), independent physical activity and rehabilitation (p = 0.020) were faster in the intervention group. No features of local anaesthetic drug toxicity or complications of the ESP block were observed. The bilateral ESP block together with intraoperative intercostal nerve cryoablation performed prior to Nuss correction of funnel chest were more effective in terms of pain control.

Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review

Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

Introduction

The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.

Methods

An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05.

Results

A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.

Conclusion

The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Modified bar bending method of thoracoscopic nuss procedure on pectus excavatum: a retrospective single-center study

BACKGROUND

Pectus excavatum (PE) is the most common disease of chest wall deformity, with an incidence of 1 in 300-400 births. Nuss procedure has proved to be the best surgical treatment method and has been widely used after clinical use for 30 years. We aimed to review the clinical data of pectus excavatum (PE) of thoracoscopic Nuss procedure adopted the Modified bar bending method of the six-point seven-section type, and compare it with the traditional curved bar bending method to explore the clinical application effect.

METHODS

Forty-six cases of clinical data were summarized of children with PE who adopted the treatment of the Modified bar bending method of the six-point seven-section type from January 2019 to December 2021, and 51 cases were compared of PE children who adopted the treatment of traditional curved bar bending method from January 2016 to December 2018, including the data of age, gender, preoperative symptoms, symmetry, Haller index, operation time, bar bending time, intraoperative bleeding, postoperative complications, bar migration, postoperative effect evaluation, etc. RESULTS: The Procedure duration (P = 0.008), bar bending time (P < 0.001), and duration of postoperative pain (P < 0.001) were reduced significantly, and the incidence of bar migration after surgery was reduced as well by the modified bar bending method. There was no difference compared with traditional Nuss produce, like the incidence of evaluation of postoperative effects (Excellent, P = 0.93; Good, P = 0.80; Medium, P = 1.00; Poor, P = 1.00), bar migration (P = 1.00), postoperative complications (P = 1.00), Clavien- Dindo classification of surgical complications (I = 0.165; II = 1.00; IIIa = 1.00; IIIb = 1.00; VI = 1.00; V = 1.00), operative safety, and operative validity.

CONCLUSION

Modified bar bending method of the six-point seven-section type, which is a kind of surgical method worth applying and popularizing, and the advantages of minimally procedure duration, bar bending time, and duration of postoperative pain, compared with the traditional bar bending method.